Uterine Artery Embolization - Lieberman's eRadiology ... may detach from the uterus after UAE ... -appropriate for pedunculated subserosal leiomyomata. z. Uterine Artery Embolization

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Text of Uterine Artery Embolization - Lieberman's eRadiology ... may detach from the uterus after UAE ......

  • Uterine Artery Embolization

    Arghavan SallesAdvanced RadiologySeptember 15, 2005

    Arghavan Salles MSIVGillian Lieberman, MD

  • Arghavan Salles MSIVGillian Lieberman, MD

    Overview

    I. Case presentationII. Imaging and leiomyomataIII. Classification of leiomyomataIV. Selection for UAEV. UAE techniqueVI. Post-procedural care and complicationsVII. Further investigationsVIII. References

  • Arghavan Salles MSIVGillian Lieberman, MD

    HistoryUterine artery embolizations (UAE, also known as uterine fibroid embolization, UFE) have been performed since the 1970s for hemostasis in women post-partum, post-cesarean, post-abortion, post-hysterectomy1-3It has also been used to treat arteriovenousmalformations of the pelvis, placenta previa, and placenta accretaIn 1995, Ravina and Herbreteau1 were the first to report the use of UAE for treatment of leiomyomataafter having incidentally noted shrinkage of fibroids when using UAE for the above indications

  • Arghavan Salles MSIVGillian Lieberman, MD

    Case46 year old woman with menorrhagiaUp to 24 consecutive days of menstruation per cycleAlso feels abdominal pressurePast medical and surgical history non-contributoryUltrasound revealed fibroids prior to consultation with the interventionalistPap smear and endometrial biopsy WNL

  • Arghavan Salles MSIVGillian Lieberman, MD

    Work-up of Patients for UAE4

    General medical history and physical examination-important to ask about symptoms, pregnancy history, recent Pap smears, and infection as part of complete history

    Gynecologic examination-important to rule out other causes for symptoms

    Laboratory testing-typically order CBC, PT/PTT/INR, BUN/creatinine to assess for anemia, coagulopathy, renal insufficiency

    Imaging-Ultrasound or MRI

    Pap test

  • Arghavan Salles MSIVGillian Lieberman, MD

    Epidemiology of LeiomyomataOccur in 20-40% of women of reproductive age4,5Account for 30-70% of hysterectomies in the United States4-5Most common benign indication for hysterectomy320-50% of women with leiomyomata have menorrhagia, dysmenorrhea, pelvic pressure, urinary frequency, pain, infertility, or a palpable abdominal-pelvic mass4,8Most common symptoms are heavy menstrual bleeding (78%), pain (59-75%), and bulk-related (82-98%)4,7,9Occur most often and at a younger age and larger size of lesions in black women7

  • Arghavan Salles MSIVGillian Lieberman, MD

    Differential Diagnosis10

    It is important to exclude other pelvic pathology that may be contributing to the patients symptoms in order to determine whether UAE is appropriate.Diffuse adenomyosis (ectopic endometrial glands and stroma within the myometrium)-symptoms are often similar to those resulting from leiomyomata

    Focal adenomyosis (adenomyoma)-may be distinguished from leiomyomata on MRI11

  • Arghavan Salles MSIVGillian Lieberman, MD

    Differential Diagnosis, cont.Solid adnexal massFocal myometrial contraction-transient phenomenon that mimics leiomyomata and disappears with repeat imaging

    Uterine leiomyosarcoma-often difficult to distinguish on imaging studies-in over 1400 patients who had hysterectomy for presumed leiomyomata followed for five years, 0.49% had leiomyosarcoma12

  • Arghavan Salles MSIVGillian Lieberman, MD

    MRI for Pre-operative PlanningMR is the most accurate imaging technique for detection and localization of leiomyomata for pre-operative planning2,4,9,10,12-14-Ultrasound may be used but is less accurate, especially in obese patientsMR is 90% sensitive and specific for adenomyosis11Treatment options vary depending on characterization of lesions (see Treatment Options)Important to determine depth of extension into myometrium to minimize risk of uterine perforation for anticipated hysteroscopic resections10

  • Arghavan Salles MSIVGillian Lieberman, MD

    MRI for Pre-operative Planning, cont.

    Pedunculated subserosal and submucosalleiomyomata may detach from the uterus after UAE-pedunculated subserosal leiomyomata may settle into the pelvis becoming a nidus of infection-pedunculated submucosal leiomyomata may be passed or may become lodged in the cervix or vagina becoming a nidus of infection10

    Uterine arteries seen with MRA may help guide embolization10MRA may help exclude contributions to the leiomyomata from ovarian or other vessels10MRI may help predict post-procedural outcome12

  • Arghavan Salles MSIVGillian Lieberman, MD

    Effect of MRI on Diagnosis14

    Interventional radiologists were asked to give pre-imaging and post-imaging diagnoses and treatment plans for 60 women evaluated for UAEAxial HASTE, Axial GRE, Sagittal T2 TSE, and coronal SHARP series were usedInitial diagnoses changed in 18% of casesMRI detected unsuspected pelvic masses, demonstrated adenomyosis, detected degenerated fibroids, and documented lack of pelvic pathologyChanged treatment plans in 22% of cases-57/60 were to undergo UAE prior to imaging-After MR, 8 went to surgery, 2 had clinical management, and one had biopsy

  • Arghavan Salles MSIVGillian Lieberman, MD

    MRI Characteristics

    Nondegenerated uterine leiomyomata are well-circumscribed masses with homogeneously decreased signal intensity compared to the outer myometrium on T2-weighted images10

    Cellular leiomyomas may have higher signal intensity on T2-weighted images and enhance post-contrast10

  • Arghavan Salles MSIVGillian Lieberman, MD

    MRI Characteristics, cont.Degenerated leiomyomata have variable appearances depending on the type of degeneration10-hyaline or calcific degeneration has low signal on T2-weighted images-Cystic degeneration has high signal on T2-weighted images. Cystic areas do not enhance post-contrast.-Myxoid degeneration has very high signal on T2-weighted images and may enhance minimally post-contrast.-Necrotic lesions have variable intensity on T1-weight images and have low signal on T2-weighted images.

    It is important to assess enhancement because lesions that do not enhance are not as likely to respond well to embolization

  • Arghavan Salles MSIVGillian Lieberman, MD

    MRI Characteristics, cont.Dont forget our differential diagnoses:

    Focal myometrial contraction-low signal on T2-weighted images11Adenomyosis-low myometrial signal intensity, enlarged junctional zone* (>12 mm), high signal intensity foci (myometrial cysts), poor definition of endomyometrial junction, and poor definition of lesion borders11Adenomyoma-focal thickening of junctional zone, poorly defined margins, minimal mass effect11

    *junctional zone is between the endometrium and myometrium and consists mostly of smooth muscle

  • Arghavan Salles MSIVGillian Lieberman, MD

    Normal Uterus

    Endometrial stripe

    Uterus

    Cervix

    Vagina

    T2-weighted sagittal image

    Bladder

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Our patient

    T2-weighted sagittal image showing leiomyomata in various locations with homogenous signal characteristics

    Subserosal

    Intramural

    Endometrial stripe

    Uterus

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Our patient

    T2-weighted axial image of the same patient

    Intramural

    Endometrial stripe

    Uterus

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Vasculature

    T1-weighted post-contrast image in the same patient showing enhancement of leiomyomata with dilated uterine arteries (white arrows)

    Enhancement

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Classification of Leiomyomata10

    Most commonly occur in the myometrium of the uterus but may occur in cervix (8% of the time)Submucosal-project into endometrial canal-least common subtype but most often symptomatic

    Intramural-within myometrium-most common subtype, usually asymptomatic

    Subserosal-beneath the serosa-if pedunculated, may torse and cause pain or infection

    Ghai, et al.

  • Arghavan Salles MSIVGillian Lieberman, MD

    Submucosal

    Intramural

    SubserosalAdenomyosis(junctional zone measures ~15 mm)

    Examples of Leiomyomata

    T2-weighted sagittal image PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    More examples

    Submucosal Intramural

    T2-weighted sagittal image T2-weighted sagittal image

    Endometrial stripe

    Endometrial stripe

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Enhancement

    T1-weighted axial image prior to administration of contrast showing homogeneous low signal in leiomyomata

    T1-weighted axial image after administration of contrast showing enhancement of leiomyoma

    Leiomyoma Enhancement

    PACS, BIDMC

  • Arghavan Salles MSIVGillian Lieberman, MD

    Indications for Intervention10

    Bleeding-most frequent symptom, usually manifests as menorrhagia or menometrorrhagia-menstrual irregularities may be due to loss of symmetric uterine contractions

    Pressure on adjacent organs-mass effect on the bladder may cause urinary frequency or incontinence-may cause hydroureter or hydronephrosis if impinging on the ureter-may cause constipation due to effects on the rectum

  • Arghavan Salles MSIVGillian Lieberman, MD

    Indications for Intervention, cont.Pain-usually due to acute degeneration which can often occur during pregnancy-may be secondary to torsion of subserosal lesions or prolapse of submucosal lesions

    Infertility-may occur as a result of compression of the fallopian tubes from intramural leiomyomata in the cornual regions or intraligamentous regions-may be a result of faulty implantation due to submucosal lesions